The relevance of ‘mixed anxiety and depression’ as a diagnostic category in clinical practice

Abstract

According to ICD-10 criteria, mixed anxiety and depressive disorder (MADD) is characterized by co-occurring, subsyndromal symptoms of anxiety and depression, severe enough to justify a psychiatric diagnosis, but neither of which are clearly predominant. MADD appears to be very common, particularly in primary care, although prevalence estimates vary, often depending on the diagnostic criteria applied. It has been associated with similarly pronounced distress, impairment of daily living skills, and reduced health-related quality of life as fully syndromal depression and anxiety. Although about half of the patients affected remit within a year, non-remitting patients are at a high risk of transition to a fully syndromal psychiatric disorder. The validity and clinical usefulness of MADD as a diagnostic category are under debate. It has not been included in the recently released DSM-5 since the proposed diagnostic criteria turned out to be not sufficiently reliable. Moreover, reviewers have disputed the justification of MADD based on divergent results regarding its prevalence and course, diagnostic stability over time, and nosological inconsistencies between subthreshold and threshold presentations of anxiety and depressive disorders. We review the evidence in favor and against MADD and argue that it should be included into classification systems as a diagnostic category because it may enable patients to gain access to appropriate treatment early. This may help to reduce patients’ distress, prevent exacerbation to a more serious psychiatric disorder, and ultimately reduce the societal costs of this very common condition.

Symptom profiles of late‐life anxiety and depression: The influence of migration, religion and loneliness

“…Thus, Beekman et al () estimated that 47–50% of older depressed individuals had a comorbid anxiety disorder. Several review papers suggest that mixed anxiety‐depression is the typical presentation in the elderly (Möller et al, ). However, because both are comorbid across the life‐cycle, the utility of including a mixed anxiety‐depression disorder specifically for older groups remains ambiguous, and more evaluation is required to establish a mixed anxiety‐depression construct in older people before regarding it as a distinctive presentation.…”

“…Moreover, its efficacy as a diagnostic class remains under dispute (Möller et al, )—it was not incorporated into the recently released DSM‐5 because the suggested diagnostic criteria were evaluated and classed as not adequately reliable. Experts have contested the interpretation of MADD based on conflicting results concerning both its diagnostic stability over time, and nosological inconsistencies between subthreshold and threshold presentations of anxiety and depressive disturbances (Möller et al, ).…”

“…Thus, Beekman et al (2000) estimated that 47-50% of older depressed individuals had a comorbid anxiety disorder. Several review papers suggest that mixed anxietydepression is the typical presentation in the elderly (Möller et al, 2016).…”

“…Moreover, its efficacy as a diagnostic class remains under dispute (Möller et al, 2016)-it was not incorporated into the recently released DSM-5 because the suggested diagnostic criteria were evaluated and classed as not adequately reliable. Experts have contested the interpretation of MADD based on conflicting results concerning both its diagnostic stability over time, and nosological inconsistencies between subthreshold and threshold presentations of anxiety and depressive disturbances (Möller et al, 2016). Zinbarg et al (1994) carried out research on the DSM-IV and noted that patients endorsing criteria for MADD were as prevalent as those with depression, impairment reported by those with MADD was comparable to that of depression and anxiety.…”

Trying to describe mixed anxiety and depression: Have we lost our way?

“…Its derivation is also obscure, and it serves only to further confuse matters diagnostically. As Möller et al () point out, the criteria are closely related to the anxious symptom scale proposed by Goldberg, Prisciandaro, and Williams () for the primary health care version of ICD‐11. For comparison, the DSM‐5 criteria are shown alongside the ICD‐11 proposal in Table .…”